INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 23-24, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Abstinent Living at the Turning Point at Washington, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel and training records, the facility failed to provide documentation of HIV/AIDS training in one of one personnel record.The findings include:Five personnel records were reviewed on April 23-24, 2013 . Per regulation, staff persons shall receive a minimum of four hours of TB/STD training and six hours of HIV/AIDS training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training within the first two years of employment. The facility did not document the required HIV/AIDS training in personnel record # 3. Employee # 3 was hired on September 20, 2010 as a counselor assistant. This employee was required to obtain six hours of HIV/AIDS the training by September 20, 2011. There was no documentation provided that the employee had completed the required training as of the licensing inspection. The Operations Manager was interviewed on April 24, 2013 and confirmed the findings.
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Plan of Correction
The operations manager confirms that Employee #3 did not have the required training. Employee #3 received the required training on 5/15/13. Additionally, all future trainings will be scheduled as soon as possible, and as required, within the first year/two years(as appropriate), by the operations manager and business manager. This will be overseen by the project director. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of two personnel records.The findings include:Five personnel records were reviewed on April 23-24, 2013. Two personnel records pertained to counselors. Two personnel records required the completion of 25 clock hours of annual training. The facility training year is from July through June. The 2011-2012 training year was reviewed. The facility failed to document 25 clock hours of annual training in personnel record # 2.Employee # 2 was hired on January 24, 2006. There were 0 clock hours of annual training documented in the employee's record for the July 1, 2011 to June 30, 2012 training year. The Operations Manager was interviewed on April 24, 2013 and confirmed the findings.
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Plan of Correction
The operations manager confirms that Employee #2 did fail to complete the required training hours. The requirement has been reviewed with all applicable staff, in their clinical supervision and staff meetings. They have all been instructed that they must have 25 hours of education each year, and that the training year runs from July - June. The operations manager will monitor the training hours as completed to ensure compliance. This will be overseen by the project director. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document psychosocial evaluations that provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in three of five client records . The findings include:Six client records were reviewed on April 25, 2013. Five client records reviewed required documentation of a psychosocial evaluation. The facility did not document a psychosocial evaluation that included a composite picture of the client's problems and needs to be addressed in treatment, the client's assets and strengths, support systems, coping mechanisms, the negative factors that might inhibit treatment and/or the client's attitude towards treatment in client records # 2, 4 and 6. Client # 2 was admitted on July 27, 2012 and discharged on January 24, 2013. The psychosocial evaluation, completed on August 6, 2012 consisted of historical and client reported information of the client's problems and needs, assets and strengths, support systems and the client's attitude towards treatment. There was no clinical evaluation of the client's status. Client # 4 was admitted on November 8, 2012. The psychosocial evaluation, completed on November 10, 2012 consisted of historical and client reported information of the client's problems and needs, assets and strengths and support systems. There was no clinical evaluation of the client's status. Client # 6 was admitted on November 16, 2012. The psychosocial evaluation, completed on November 28, 2012 consisted of historical and client reported information of the client's problems and needs, coping mechanisms, the negative factors that might inhibit treatment and the client's attitude towards treatment. There was no clinical evaluation of the client's status. The Facility Director and the Operations Manager were interviewed on April 25, 2013 and did not dispute the findings.
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Plan of Correction
While the required psychosocial evaluations were completed, our staff did not indicate a clinical evaluation of the client's status in some cases. This requirement has been reviewed with applicable staff in their clinical supervision and staff meetings. The project director will ensure that all psychosocial evaluations include a clinical evaluation of the client's status. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on the review of client records, the facility failed to document treatment and rehabilitation plan updates that included an assessment of the client's progress in relationship to the stated goals on of the treatment and rehabilitation plan in five of five client records. The findings include:Six client records were reviewed on April 23-24, 2013. Five client records reviewed required treatment plan updates. Per regulations, treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. The facility did not document an assessment of the client's progress in relationship to the stated goals of the treatment and rehabilitation plan in client records # 2, 3, 4, 5 and 6. Client # 2 was admitted on July 27, 2012 and discharged on January 24, 2013. The treatment and rehabilitation plan was completed on August 6, 2012. Updates, completed in September, October, November, December 2012 and January 2013 listed only "did not do this" or "did this" under each goal and did not include an assessment of the client's progress in relationship to the stated goals of the treatment and rehabilitation plan. Client # 3 was admitted on February 17, 2012 and discharged on August 16, 2012. Updates, completed in June, July and August 2012 listed only "did not do this" or "did this" under each goal and did not include an assessment of the client's progress in relationship to the stated goals of the treatment and rehabilitation plan Client # 4 was admitted on November 8, 2012 The treatment and rehabilitation plan was completed on November 23, 2012. Updates, completed in December 2012, and January, February and March 2013 listed only "did not do this" or "did this" under each goal and did not include an assessment of the client's progress in relationship to the stated goals of the treatment and rehabilitation plan. Client # 5 was admitted on January 10, 2013. The treatment and rehabilitation plan was completed on February 2, 2013. Updates, completed in March and April, 2013 listed only "did not do this" or "did this" under each goal and did not include an assessment of the client's progress in relationship to the stated goals of the treatment and rehabilitation plan. Client # 6 was admitted on November 16, 2012 The treatment and rehabilitation plan was completed on November 23, 2012. Updates, completed in December 2012, and January, February and March 2013 listed only "did not do this" or "did this" under each goal and did not include an assessment of the client's progress in relationship to the stated goals of the treatment and rehabilitation plan. The facility Director and Operations Manager were interviewed on March 25, 2013 and did not dispute the findings.
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Plan of Correction
While the required treatment and rehabilitation plan updates were completed, our staff only listed "did not do this" or "did this", and did not include an assessment of the client's progress in relationship to the stated goals of the treatment and rehabilitation plan. This requirement has been reviewed with applicable staff in their clinical supervision and staff meetings. The project director will ensure that all treatment and rehabilitation plan updates include an assessment of the client's progress in relationship to the stated goals of the treatment and rehabilitation plan. |